Tracheobronchial Ruptures due to Cuffed Carlens Tubes

Tracheobronchial Ruptures due to Cuffed Carlens Tubes Natalino Guernelli, M.D., Romano B. Bragaglia, M.D., Antonio Briccoli, M.D., Mario Mastrorilli, M.D., and Roberto Vecchi, M.D. ABSTRACT At our institution in the past 22 years, more than 3,000 patients have undergone chest procedures, and 2,700 of them were intubated with a cuffed Carlens endotracheal tube. In this paper we report on 5 patients with tracheobronchial ruptures caused by intubation with these tubes. We believe this hazard should be brought to the attention of physicians.

Tracheobronchial ruptures are rare complications of intubation with cuffed Carlens endotracheal tubes. Reference in the literature to these ruptures is scanty [l-41. This is probably because they have not been described or diagnosed very often, although some unexplainable, inexhaustible pneumothoraces discovered in the immediate postoperative period could be due to this lesion. In our institute, more than 3,000 patients underwent a chest procedure during the period 1956 to 1978, and in about 2,700 of them, a Carlens tube was used. We observed tracheobronchial ruptures in 5 patients. Two were undergoing operation for bronchial adenoma, 1 for lung cancer, 1 for chronic empyema, and 1 for cancer of the lower thoracic esophagus. The most common site of rupture was the distal portion of the trachea and left main bronchus in the pars membranacea or at its junction with the pars cartilaginea. In this report we discuss briefly the causes of these lesions, their diagnosis and treatment, and, above all, the best ways to prevent their occurrence. Tracheobronchial ruptures are complications that result from measures such as using an inadequate tube size, malpositioning the tip of the tube, or insufflating the balloon From the Clinica Chirurgica, University of Bologna, Bologna, Italy. Accepted for publication Nov 3, 1978. Address reprint requests to Dr. Bragaglia, Clinica Chirurgica, University of Bologna, Bologna, Italy.

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too rapidly, which does not allow for adaptation of the tracheobronchial wall. These and other harsh maneuvers are all the more dangerous in the presence of tracheomalacia. Tracheobronchial lesions can be diagnosed during operation, as in 3 of our patients, or in the immediate postoperative period. Intraoperative diagnosis is made by careful inspection of the mediastinum when sudden insufficient ventilation is detected or when steps such as hemostasis or lymphadenectomy are performed in patients with cancer. Postoperative diagnosis usually is done by bronchoscopy, which is indicated whenever there is a serious persistent pneumothorax. Surgical treatment consists of closing the lesion with interrupted sutures while keeping in mind the basics of tracheal operation. The Table summarizes the history of the 5 patients reported on here. Patient 1 A 57-year-old man came to our outpatient clinic after experiencing dysphagia for a month. After a roentgenographic series was made and after endoscopy was performed and biopsy specimens were studied, the diagnosis of carcinoma of the lower thoracic esophagus was made. The patient was intubated with a Carlens tube to exclude the left lung. The tumor was approached through a left thoracotomy and laparotomy. A total gastrectomy with resection of 7 cm of esophagus was performed, and the procedure ended with an esophagojejunoduodenoplasty. The immediate postoperative period was complicated by intense dyspnea. Blood gas analysis revealed the following values: Po,, 71 mm Hg; 0, saturation, 80%; Pco2, 70 mm Hg; pH, 7.21; base excess, -7 mEqlL. A chest roentgenogram showed that the right lung was collapsed; the right chest was immediately drained and a waterseal was applied. Since the pneumothorax seemed inexhaustible,

0003-4975/79/070066-03$01.25 @ 1978 by Natalino Guernelli

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Guemelli et al: Tracheobronchial Ruptures

Summary of Data for 5 Patients with Tracheobronchial Rupture Patient No., Sex, Age (yr)

Date of Operation

1. M, 57

Results Indication for Operation

Operation

7/25/73

Cancer of esophagus

Total esophagectomy Right main bronchus with coloplasty

2. F, 23

3/6/73

Right bronchial adenoma

3. M, 54

5/21/74

4. F, 63

1/22/75

5. F, 70

6/13/75

Right superior lobectomy with plasty of main left bronchus Right Right empyema pleuropneumonectomy Right lung cancer Right pneumonectomy

Right bronchial adenoma

Right inferior lobectomy

bronchoscopy was performed, which showed that the tip of the Carlens tube had produced a 2 cm laceration of the lateral wall of the main bronchus. Although an emergency repair was carried out, the patient died of mediastinitis after four days.

%

Site of Lesion

Immediate

Long-Term

Died of acute mediastinitis on postop. day 4 Good

Alive and well

Carina to superior left bronchus Left wall of lower trachea

Good

Alive and well

Good

Right tracheobronchial rupture

Good

Died 1 year postop. of cerebral metastasis Alive and well

Lower trachea and left main bronchus

left bronchus was repaired with interrupted sutures. Bronchography two years after operation showed a perfectly patent right tracheobronchioplasty with normal pulmonary expansion. The left tracheobronchial suture over the laceration had healed perfectly without stricture and irregularity of the bronchial wall.

Patient 2 A 23-year-old woman underwent operation for Patient 3 bronchial adenoma of the right upper lobe A 54-year-old man was seen who, in 1947, bronchus involving the main bronchus. The underwent artificial pneumothorax for a tuberprocedure consisted of right superior lobec- culosis cavitation of the right lung, which led to tomy, with plasty of the main bronchus. At op- a fibrothorax. A year before he came to our ineration, the right upper lobe bronchus was sec- stitution, he began to cough small amounts of tioned, sparing part of the anterior segmental blood. The hemoptysis increased in intensity bronchus, which was to be used as a patch for with time. A chest series showed a right the bronchoplasty. During sectioning of the chronic empyema, and, at bronchoscopy, blood bronchus, a serious ventilation insufficiency was seen coming from the inferior right bronoccurred, and we immediately did a thorough chus. The programmed right pleuropneumoexploration of the mediastinum. Hidden be- nectomy was uneventful. However, at the end hind the bronchus intermedius and coming of hemostasis before the chest was closed, out of a large rupture in the posterior trachea the balloon of the Carlens tube was seen comand left main bronchus was the balloon of the ing from the left main bronchus through a Carlens tube. The left main bronchus was im- wide laceration, which ran from the carina to mediately intubated through the laceration to the opening of the superior bronchus. The ventilate the left lung, and the planned proce- tracheobronchial laceration was immediately dure was carried out on the right lung. Once the sutured. Twenty-five days later, the patient was plasty had been performed, the right bronchus seen at the outpatient clinic in satisfactory conwas intubated per 0s and the laceration of the dition.

68 The Annals of Thoracic Surgery Vol 28 No 1 July 1979

Patient 4 A 63-year-old woman had a routine chest roentgenogram, which demonstrated a mass in the inferior right lobe. Bronchoscopy revealed a tracheobronchomalacia and the biopsy specimen was described by the pathologist as adenosquamous carcinoma. The programmed pneumonectomy was very difficult to perform since there had been problems with intubation and the lung was not fully excluded. After pneumonectomy, the surgeon noticed that the tip of the Carlens tube had caused a laceration of the trachea, and repair was performed immediately. A control bronchoscopy showed the repair to be successful. The patient was discharged and led a normal life for a year. Then a cerebral metastasis caused her death.

mouth. Another tube was passed through the nose and pulled out of the mouth. The ends of the two tubes were fixed together and the end of the positioned tube was gently pulled out of the nose. The end result was that a small tube was inserted into the laceration and came out of the nose. It was slowly withdrawn as healing progressed.

Comment We draw the following conclusions from our limited experience in tracheobronchial ruptures from endotracheal intubation with Carlens tubes: Repair with interrupted sutures is sufficient. Postoperative bronchoscopy must be carried out immediately whenever an unexplainable, inexhaustible pneumothorax is observed. Repair must be performed as soon as the lesion is diagnosed. The incidence of lesions to the trachea and bronchi can be decreased further by avoiding harsh maneuvers, slowly insufflating the cuff, and never forcing a resistance encountered during intubation.

Patient 5 A 70-year-old woman was referred to our institute because of recurrent episodes of bronchopneumonia. A chest series, bronchoscopy, and biopsy specimens revealed an endobronchial adenoma (cylindroma)obstructing the posterior segmental bronchus of the right inferior References Bisson A, Germain V: Rupture bronchique par un lobe. Right inferior lobectomy was performed. ballonet de sonde de Carlens. Ann Chir Thorac The postoperative period was uneventful. A Cardiovasc 15:49, 1976 control bronchoscopy performed ten days later Couniot J, Santy P: Rupture de la trachee au cours revealed a small right tracheobronchial lacerad'une anesthesie avec intubation pas sonde a tion probably caused by the tip of the Carlens ballonet. Lyon Chir 50:104, 1955 Elman A, Hay JM, Konrat N, et al: Rupture de la tube. The laceration was managed conservatrachee par un ballonet de sonde d'intubation tively. A very thin tube was positioned through tracheale. Ann Chir Thorac Cardiovasc 12:423, a bronchoscope that had been passed through 1973 the trachea and was then carefully withdrawn, Tornvall SS, Jackown KH, Oyandel E: Tracheal leaving the small tube with its tip in the lacerarupture complication of cuffed endotracheal tube. Chest 59:237, 1971 tion and the other end coming out of the